overview

Depressive disorders include a range of conditions characterized by a sad, empty, or irritable mood, along with somatic (physical) and cognitive changes that impair functioning. What distinguishes these disorders are their duration, timing, and etiology (cause or origin). Here’s a brief overview of key depressive disorders and their defining features:

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Exam Tip: Focus on Duration and Etiology: Differentiate between disorders based on timeframes (e.g., two weeks for MDD vs. two years for PDD) and causes (e.g., substance use, medical conditions).

disruptive mood dysregulation disorder

Diagnostic Criteria Highlights:

1. Severe Temper Outbursts:
   • Verbal (e.g., rages) or behavioral (e.g., physical aggression toward people/property).
   • Out of proportion to the situation and inconsistent with developmental level.
2. Persistent Irritable or Angry Mood:
   • Present most of the day, nearly every day between outbursts.
   • Observable by others (e.g., parents, teachers, peers).
3. Frequency and Duration:
   • Outbursts occur ≥3 times per week (Criterion C).
   • Symptoms persist for ≥12 months, with no relief longer than 3 consecutive months (Criterion E).
4. Setting Requirements:
   • Symptoms occur in 2 of 3 settings (home, school, peers) and are severe in at least one (Criterion F).
5. Age Parameters:
   • Diagnosis is made between ages 6–18, with onset of symptoms before age 10 (Criteria G and H).
6. Exclusions:
   • Cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder.
   • Can coexist with ADHD, major depressive disorder, conduct disorder, or substance use disorders.
   • Not attributable to substance use or another medical/neurological condition.

major depressive disorder

Diagnostic Criteria:

1. Core Symptoms (Criterion A):
   • Five or more symptoms must be present during the same two-week period, representing a change from previous functioning.
   • At least one symptom must be either depressed mood or loss of interest/pleasure.
   • Symptoms:
     1. Depressed mood (or irritability in children/adolescents) most of the day, nearly every day.
     2. Loss of interest or pleasure in activities.
     3. Significant weight or appetite changes.
     4. Sleep disturbances (insomnia or hypersomnia).
     5. Psychomotor agitation or retardation.
     6. Fatigue or loss of energy.
     7. Feelings of worthlessness or excessive/inappropriate guilt.
     8. Difficulty concentrating or indecisiveness.
     9. Recurrent thoughts of death, suicidal ideation, or suicide attempts.
2. Functional Impact (Criterion B):
   • Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
3. Exclusions (Criteria C, D, E):
   • Not due to substance use or another medical condition.
   • Not better explained by schizoaffective disorder or other psychotic disorders.
   • No history of manic or hypomanic episodes (unless substance- or medically induced).

Specifiers:

• • Use to provide additional context about the episode:
    • Severity: Mild, moderate, severe.
    • Psychotic Features: Mood-congruent or mood-incongruent.
    • Remission Status: Partial or full.
    • Other Specifiers “With”:
      • anxious distress
      • mixed features
      • melancholic features
      • atypical features
      • catatonia
      • peripartum onset
      • seasonal pattern

Persistent Depressive Disorder (PDD)

Diagnostic Criteria Highlights:

1. Core Symptom: Persistent Depressed Mood (Criterion A):
   • Depressed mood for most of the day, for more days than not, for at least:
     • Two years in adults.
     • One year in children/adolescents (mood can be irritable).
2. Associated Symptoms (Criterion B):
   • At least two or more of the following during periods of depressed mood:
     1. Poor appetite or overeating.
     2. Insomnia or hypersomnia.
     3. Low energy or fatigue.
     4. Low self-esteem.
     5. Poor concentration or difficulty making decisions.
     6. Feelings of hopelessness.
3. Symptom Duration (Criterion C):
   • Symptoms are persistent, with no symptom-free periods lasting longer than 2 months.
4. Co-occurrence with Major Depressive Episodes (Criterion D):
   • Major depressive episodes may occur during the course of PDD.
   • If MDD criteria are met fortwo years, both diagnoses (PDD and MDD) should be given.
5. Exclusions:
   • No history of manic or hypomanic episodes (Criterion E).
   • Symptoms not better explained by schizophrenia spectrum disorders or another psychotic disorder (Criterion F).
   • Not attributable to substances or a medical condition (Criterion G).
6. Functional Impact (Criterion H):
   • Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

Specifiers:

1. Onset:
   • Early onset: Before age 21.
   • Late onset: At or after age 21.
2. Patterns (most recent 2 years) “With”:
   • pure dysthymic syndrome: No major depressive episode in the past 2 years.
   • persistent major depressive episode: Full MDD criteria met for the entire 2 years.
   • intermittent major depressive episodes, with current episode: Current MDD episode, but periods below threshold within 2 years.
   •  intermittent major depressive episodes, without current episode: MDD episodes occurred in the past 2 years but are not current.
3. Severity:
   • Mild, Moderate, or Severe.

Premenstrual Dysphoric Disorder (PMDD)

Diagnostic Criteria Highlights:

Diagnostic Criteria Summary:

1. Timing of Symptoms (Criterion A):
   • Symptoms must occur in the final week before menses, improve within a few days after onset of menses, and be minimal or absent in the week after menses.
   • Symptoms must be present in most menstrual cycles over the past year.
2. Core Mood Symptoms (Criterion B):
   • At least one or more of the following must be present:
     1. Marked mood swings or affective lability.
     2. Marked irritability, anger, or interpersonal conflict.
     3. Marked depressed mood, hopelessness, or self-deprecation.
     4. Marked anxiety, tension, or being “keyed up.”
3. Additional Symptoms (Criterion C):
   • A total of five or more symptoms (from Criteria B and C combined) must be present.
   • Examples include:
     • Decreased interest in usual activities.
     • Difficulty concentrating.
     • Fatigue or lack of energy.
     • Appetite changes or cravings.
     • Insomnia or hypersomnia.
     • Feeling overwhelmed or out of control.
     • Physical symptoms (e.g., breast tenderness, bloating, joint/muscle pain).
4. Functional Impact (Criterion D):
   • Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
5. Exclusions (Criteria E, G):
   • Symptoms are not an exacerbation of another disorder (e.g., major depressive disorder, generalized anxiety disorder).
   • Not attributable to substances or a medical condition.
6. Confirmation (Criterion F):
   • Diagnosis should be prospectively confirmed by daily symptom ratings across at least two symptomatic cycles.
   • A provisional diagnosis can be made before confirmation.

Substance/Medication-Induced Depressive Disorder

Diagnostic Criteria Highlights:

1. Core Mood Disturbance (Criterion A):
   • A prominent and persistent depressed mood or markedly diminished interest or pleasure in almost all activities.
2. Substance/Medication Link (Criterion B):
   • Timing: Symptoms develop during or soon after:
     1. Substance intoxication or withdrawal, or
     2. Exposure to or withdrawal from a medication.
   • Capability: The substance or medication is known to cause depressive symptoms.
3. Exclusion of Independent Depressive Disorder (Criterion C):
   • Symptoms are not better explained by a pre-existing depressive disorder. Evidence for an independent depressive disorder includes:
     • Symptoms precede substance/medication use.
     • Symptoms persist for a substantial time (e.g., ~1 month) after withdrawal or intoxication.
     • History of recurrent depressive episodes not related to substance/medication use.
4. Delirium Exclusion (Criterion D):
   • Symptoms do not occur exclusively during a delirium.
5. Functional Impact (Criterion E):
   • Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

Specifiers “With”:

• onset during intoxication: Symptoms occur during substance intoxication.
• onset during withdrawal: Symptoms occur during or shortly after substance withdrawal.
• onset after medication use: Symptoms develop after initiating, changing, or withdrawing from a medication.

depressive disorder due to another medical condition

Diagnostic Criteria Highlights

1. Core Mood Disturbance (Criterion A):
   • Prominent and persistent depressed mood or markedly diminished interest or pleasure in almost all activities that dominates the clinical picture.
2. Direct Medical Cause (Criterion B):
   • Evidence from history, physical exam, or lab findings that the depressive symptoms are a direct physiological consequence of another medical condition.
3. Exclusion of Other Disorders (Criterion C):
   • Symptoms are not better explained by another mental disorder (e.g., adjustment disorder with depressed mood, where the stressor is a medical condition).
4. Delirium Exclusion (Criterion D):
   • Symptoms do not occur exclusively during the course of a delirium.
5. Functional Impairment (Criterion E):
   • Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specifiers:

1. With Depressive Features:
   • Depressive symptoms are present but do not meet full criteria for a major depressive episode.
2. With Major Depressive–Like Episode:
   • Symptoms meet full criteria for a major depressive episode, except Criterion C.
3. With Mixed Features:
   • Symptoms of mania or hypomania are also present but do not predominate in the clinical picture.

other specified depressive disorder

Highlights:

• Used when depressive symptoms cause significant distress or impairment but do not meet full criteria for a specific depressive disorder.
• Clinician specifies the reason the criteria are not met (e.g., “short-duration depressive episode”).
• Examples:
  1. Recurrent Brief Depression: Depressed mood with ≥4 depressive symptoms, lasting 2–13 days, occurring monthly for 12 months, and not meeting criteria for other disorders.
  2. Short-Duration Depressive Episode: Depressed mood with ≥4 symptoms lasting 4–13 days, causing significant distress or impairment.
  3. Depressive Episode with Insufficient Symptoms: Depressed mood with ≥1 symptom, persisting ≥2 weeks.
  4. MDD Superimposed on Psychotic Disorders: Applies when a major depressive episode occurs in the context of schizophrenia or other psychotic disorders, excluding schizoaffective disorder.

unspecified depressive disorder

Unspecified depressive disorder is used when depressive symptoms cause significant distress or impairment but do not meet full criteria for a depressive disorder, and:

• The clinician chooses not to specify the reason criteria are unmet.
• Example: Limited information in settings like an emergency room.

unspecified mood disorder

Unspecified mood disorder applies when when mood disorder symptoms cause distress or impairment but it is unclear whether the presentation aligns with depressive or bipolar disorders. Example: Acute agitation without sufficient information to differentiate between unspecified depressive and bipolar disorders.

specifiers for depressive disorders

With Anxious Distress:

• Presence of at least two of the following during most days of the depressive episode:
  1. Feeling tense.
  2. Unusual restlessness.
  3. Difficulty concentrating due to worry.
  4. Fear of something awful happening.
  5. Fear of losing control.
• Severity:
  • Mild: 2 symptoms.
  • Moderate: 3 symptoms.
  • Moderate-Severe: 4–5 symptoms.
  • Severe: 4–5 symptoms with motor agitation.

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